Journal club: primary prophylaxis for SBP

This journal club evaluated the merits of primary antibacterial prophylaxis for SBP.  Two articles were reviewed.  The first was a 2007 Gastroenterology paper from Fernandez et al.  They randomized 68 patients to norfloxacin or placebo.  The key point here is: these were very sick patients: Child C, impaired renal function, ascites albumin < 1.5 g/dL.  At 3 months and 12 months of follow-up, the end-points included the probability of developing SBP, HRS and overall survival.  The probability of all three end-points was superior in the study group compared to placebo, and those present at the journal club agreed that these patients deserve daily, primary prophylaxis.

The second article by Terg et al. came from a 2009 article in Journal of Hepatology.  The main difference here was the cohort studied- clearly not as sick.  Inclusion criteria of ascites albumin level < 1.5 g/dL was used, but these patients were Child B and had preserved renal function.  While ciprofloxacin did not cut down on the number of SBP cases, the overall number of infections was significantly decreased; the number of quinolone-resistant bacterial strains increased.  There was a survival benefit as well (p<0.04); the number needed to treat was 5.  The practice of prophylaxing every Child B with low-albumin ascites is a perilous one, and the group was not convinced of its superiority.  The numbers of patients in this weakly-powered study was small.


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